Background: Peripherally inserted central catheters (PICCs) are routinely placed in hospitalized patients who are receiving long-term IV antibiotics or who have poor venous access. In our hospital, 1 in 12 patients on the Medicine service receives a PICC line at some point during a hospitalization. 35% of all hospital-acquired venous thromboembolisms (VTEs) on the Medicine service occur in the upper extremity and are related to line placement. 10% of PICC lines are placed in patients who expired within 3 months. A PICC line unnecessarily increases a patient’s risk of developing a blood stream infection. Prior to this initiative, ordering a PICC line did not require approval.
Purpose: The goal of Vascular Access Stewardship campaign is to immediately and dramatically reduce the number of PICC lines placed on Medicine patients when a safer alternative (usually a midline) is appropriate. Like antibiotic stewardship, a goal of vascular access stewardship is to educate and advise in the safest access for each patient. In addition, the campaign promotes a holistic understanding of every patient’s goals of care and confirms that the placement of a PICC line would indeed be aligned with these goals.
Description: The Vascular Access Stewardship campaign strategy is simple: every PICC line requires verbal approval from Medicine leadership prior to insertion. The initiative was championed by Medicine leadership who partnered with the vascular access nurses to create a seamless workflow. Housestaff, nurse practitioners, physician assistants and physicians were educated on the importance of carefully considering the need for every PICC line as well as the new policy requiring approval. Four members of Medicine leadership rotate the responsibility for approving PICC lines every week. The schedule and cell phone numbers is posted on AMION. For every PICC line request, Medicine leadership records the patient name, medical record number, reason for PICC request and whether or not PICC line request was granted into RedCap data entry. If a PICC is approved, the ordering provider is instructed to document “PICC line approved by Medicine leadership” in the “comments” sections of the Epic order. The vascular access nurses will only place PICC lines in patients with the appropriate notation in their order. If a PICC is not approved, there is an opportunity for Medicine leadership to further educate the provider. If a patient is being discharged on 3 weeks of IV antibiotics, Medicine leadership will suggest a midline; if a patient is not being discharged for several days, Medicine leadership will advise the provider to place the line on the day of discharge; if a PICC line is being requested in a patient with a terminal illness, Medicine leadership will suggest a Palliative consult. At the end of every week, the vascular access team provides medicine leadership with a list of all PICCs placed. This list is reconciled with the RedCap data. Any discrepancies are investigated.
Conclusions: In the two months since the start of our Vascular Access Stewardship Campaign, the number of PICC line requests and PICC line placements on the Medicine service has declined dramatically, from 72 PICCs/month to 19 PICCs/month. We believe this will be an effective strategy to reduce VTEs and CLABSIs in our patients.